Tuesday, November 26, 2013

Sexual Assault: Challenges faced by Chennai Hospitals

by Divya Bhat In the past year, sexual violence has become a topic of wide public discussion and the roles of government institutions, especially those that prosecute sexual assault cases and work with survivors, have come under increasing scrutiny. As a Shakti Fellow with The Prajnya Trust, I came to Chennai to learn a bit more about how sexual assault cases move through the legal system, and how doctors and other medical personnel view such cases. The conversations I had with individuals working within the medico-legal system described inert government institutions that needed streamlining in order to provide timely care for survivors of sexual assault.

The following blogpost is a brief compilation of some of my findings, especially in regards to the collection of forensic evidence by doctors. These findings are specific to Tamil Nadu because of state to state variation in protocols for the collection of forensic evidence, although I believe that they reflect some of the broader issues at hand in the national response to sexual assault cases.

Lack of training and system-wide delays

The role of the doctor within the Indian legal system is to provide the court with documentation of the assault, and to collect any forensic evidence that is on the body. This entails recording any wounds on the body of the survivor, taking swabs and samples, and getting a detailed account of the assault in the words of the survivor. The ability to collect forensic evidence and accurately record this evidence in legal documents is crucial to prosecuting sexual assault cases; without good forensic evidence, sexual assault cases often rely on character assessments of the survivor.

After sexual assault cases are reported to the police in Chennai, survivors are taken to large government hospitals where a doctor can examine them. Legally, any female doctor can see any female survivor of sexual assault, but these cases are often taken directly to the obstetrics and gynecology ward due to a lack of trained female forensic doctors. Gynecologists, however, do not receive sufficient practical and training to collect forensic evidence and fill out the necessary paperwork in the proper and legally admissible way. Without sound knowledge of forensic protocols or standardized training, doctors can rely on ad hoc and incomplete procedures that compromise the integrity of the forensic evidence.

While completing the forensic examination, the doctor is supposed to use a legal document called a pro forma(provided by the Tamil Nadu state government) in order to guide a doctor in noting down any relevant information. However, in practice, the pro forma is rarely utilized. Doctors may only fill out only an Accident Register copy, which is a brief assessment that all patients get when coming into the casualty ward. This document, which provides little room for description of wounds or for the survivor’s account of the attack, often becomes the basis for the medical certificate within the courtroom.

Doctors in government hospitals also face challenges while interacting with other government institutions like the police force and the judicial system. Most medical professionals expressed frustration with systemic delays that limited the doctor’s ability to collect evidence in a timely manner; nearly every doctor I spoke with suggested that examination of a survivor within 24 hours was crucial to getting the best forensic evidence. Outside of this time frame, the bodily evidence of assault gets degraded, wounds start to heal, and evidence is washed away. However, survivors of sexual assault must first file a first information report (FIR) with the police before being taken to a government hospital for examination. Many doctors pointed out that filing an FIR often takes several days, after which time most of the forensic evidence is lost. Confusion over procedural issues like getting permission from a magistrate to proceed with forensic examinations can also add to further delays. Finally, in their capacity as government employees, government doctors must make themselves available to provide expert testimony in any medico-legal case. Courts in Chennai suffer from long wait times, delays, and backlogs of cases, so doctors may have to present their medical findings in court years after the initial examination.

A move to a more therapeutic approach

While I have talked about some of the systemic constraints to providing sensitive care to survivors of sexual assault, doctors can move to a more therapeutic approach to care. Doctors, particularly gynecologists, are uniquely positioned to provide care to survivors of sexual assault and to collect the necessary forensic evidence. Nurses, and other medical personnel could also be trained to notice signs of assault and abuse, and to provide emotional support to survivors and their families. Instead of just treating patients for their immediate wounds and collecting evidence, organizations like CEHAT advocate a more therapeutic approach to care that limits the secondary trauma of reporting a sexual assault case (see CEHAT 2012). CEHAT suggests that a doctor seeking informed consent to do a forensic examination and discussing the reasons for the examination with the survivor could provide more emotional support and build trust. Additionally, follow-up with survivors after the initial examination could help assess psychological trauma or further medical complications of an assault. While institutional change within the medico-legal system is certainly required, a move to more therapeutic care will allow patients to feel more comfortable while trying to find justice after an assault.